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1. Congestive cardiac failure (aka heart failure)
It is often difficult to be certain that heart failure is contributing to dyspnea in a patient. However, in this case there is little doubt. While each key feature on its own may not be specific for heart failure, the combination in this case of dyspnea, orthopnea, ankle swelling, a history of ishaemic heart disease, an elevated CVP (raised JVP) makes the diagnosis certain. In addition, the abnormal ECG (atrial flutter) is consistent with this diagnosis (it is rare to see a case of heart failure with a completely normal ECG). Check out our video tutorial on Atrial Flutter. Also Brain Naturetic Peptide (BNP) levels are markedly increased. BNP is produced by ventricular myocytes in repsonse to stretch. BNP elevated to the level seen in this case is strongly suggestive of underlying heart failure. Although on the basis of his SpO2, our patient appears to be maintaining his oxygen saturation on room air, he is hyperventilating to acheive this. His ABG is abnormal with a raised A-a gradient of 30 mmHg (predicted = 17 mmHg) (Check out our video tutorial on the A-a Gradient). His subsequent CXR was consistent with the presence of pulmonary edema.
2. Secondary hyperaldosteronism.
The hyperaldosteronism is secondary to reduced effective intravascular volume. Understanding this statement is the key to understanding electrolyte abnormalities in a significant proportion of our patients!
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